www.jitae.orgJournalofInformationTechnologyandApplicationinEducationVol.3Iss.

4,December2014
doi:10.14355/jitae.2014.0304.09

DigitalPathologyforELearningandDigital
EducationAReview
BrianK.Chiu1,KimSolez2,ConsolatoM.Sergi3
DepartmentofLaboratoryMedicineandPathology,FacultyofMedicineandDentistry,UniversityofAlberta,
Edmonton,Alberta,Canada.
brian.chiu@albertahealthservices.ca;2kim.solez@ualberta.ca;3sergi@ualberta.ca

Abstract
Recent advances in information technology and
telecommunications have made significant improvement in
thedeliveryofeducationinpathologyusingadigitalformat.
Digitalpathology(DP)imagesarecapturedasstaticimages
byvariousscanning,imagingormobiledevices.Wholeslide
imaging/virtual microscopy (WSI/VM) can be obtained by
robotic microscopy on an entire histological glass slide.
Anonymized DP images may be stored in remote and/or
cloudserverstobeusedinELearninganddigitaleducation.
Since 1986, clinical services using telepathology (TP)
technologies for the transfer of pathology images between
distant locations have benefited many patients worldwide,
including the University of Alberta. WSI by Realtime
telepathology systems provides for a faster diagnosis in
intraoperative frozen section and teleconsultations, as well
as interactive components in digital education and
continuing medical education (CME) for purposes of
specialist recertification or revalidation for the Royal
College ofPathologistsof Canada and College of American
Pathologists. At present, the use of WSI by realtime TP
system in DP education seems to be limited due to high
bandwidth requirement and high expense, but electronic
platforms and their connection to stable operating systems
areimprovingenormously.Socialmediaandmobiledevices
are increasingly being used in DP education and may
provide future platforms for the delivery of DP education.
However, fullscale implementations of technologies in DP
education may be limited, due to limited resources and
infrastructural support, and the lack of integration into the
existing laboratory information systems (LIS) or Provincial
HealthNetworks(PHN).
Keywords
DigitalPathology;Telepathology;Elearning;DigitalEducation

Introduction
During the past two decades, the rapid advancement
of information technology (IT) and emerging
techniques have rendered many analog technologies
andcommunicationtoolsineducationobsolete.Tools
for pathology education have made such vastly
significant improvements towards digitization and

164

telecommunication that students and professionals in

healthcare, patients andeven the public of developed
countries and underdeveloped parts of the world
continue to benefit. This review summarizes the
evolutionofdigitalpathology(DP)andtelepathology
(TP)ineducationandthesignificantchallengesforthe
future in the era of rapid progression of social media
usageandadvancementofinformationtechnology.
Digital Pathology
Digitalpathology(DP)canbedefinedastheelectronic
capture, management, analysis and distribution of
gross or microscopic specimens (Bellis 2013). Digital
pathology has been deemed a disruptive technology,
which is defined as a technical innovation that
improves a product and/or service in a manner that
themarketdoesnotanticipate.(Pantanowitz2010)
StaticPathologyImages
For more than 150 years and still in practice today,
pathologistsroutinelymakethediagnosisusingalight
microscope on tissue sections layered on glass slides
and stained by hematoxylineosin staining and/or
other special stains. Teaching cases were prepared
with recut glass slides or analog color slides (plastic
projectionslides)usingfilmbasedcameramountedon
microscopes. The carousal boxes of archival slides
wereusedforclinicalroundsandeducationalseminar
presentations and occasionally for medicolegal
purposesbeingacceptedincourtproceedingsforboth
civil and criminal law systems. Nowadays, such
archival collections will have to be scanned and
converted to digital images. Microscopic images on
glass slides are now captured by digital cameras
mountedonlightmicroscopes.Ontheotherhand,the
imagesofgrosspathologyspecimenscanbecaptured
by digital cameras, iPAD, and phablets (android
tabletsandsmartphones)andtheimagesdownloaded
via SD media card, USB interphase or wireless/wifi
connections into computers or servers for storage.

JournalofInformationTechnologyandApplicationinEducationVol.3Iss.4,December2014www.jitae.org

any time. Training materials can be standardizedand

images may be made available by hyperlinks to the
file servers. (Pantanowitz, 2012) WSI has been used
for a plethora of educational activities, including
graduate schools, trainees in different medical
specialties and allied health, in Elearning and tele
education. Successes have been reported in graduate
educations for medical, (Foster 2010, Monaco, 2011)
dental, (Weaker 2009) and veterinary schools. (Dee
2007) Elearning and virtual workshops with virtual
atlases to promote webbased learning are made
available by several societies including the United
StatesandCanadianAcademyofPathology(USCAP),
and International Academy of Cytopathology (IAC).
(Khalbuss 2011) WSI is also being used for
performance improvement programs and proficiency
testingbytheCollegeofAmericanPathologists(CAP)
andisanintegralpartoftheboardexaminationofthe
RoyalCollegeofPathologistsofCanada(RCPC).WSI
isalsoanimportantmoduleforpurposesofspecialist
recertificationorrevalidationfortheRoyalCollegeof
Pathologists of Canada and College of American
Pathologists. (Sergi 2008) The diagnostic scores of the
pathologists
undergoing
the
Performance
Improvement Program in Surgical Pathology (PIP)
online do not appear compromised by the converting
toWSI.(Sharma2011)

Anonymized and digitized static images may be

stored in the computers and can be retrieved for
review, duplication, editing, or uploading for
transmission or sharing with colleagues for rounds /
multidisciplinaryteammeetings.
The digitized static pathology images are important
components of digital pathology in Elearning and
digital education. Amin and others have reported
thatdigitalgrosspathologyimagesmaybeintegrated
into enterprisewide electronic picture archiving and
communication system (PACS) for storage, rapid
retrievalandwidespreadaccess.(Amin2012)Grossing
of large pathology specimens (macroscopy) involves
specimen orientation, dissection and cutting into
thinnerslicesforformalinfixationandblocking.Inour
institution, we have been using an iPAD to capture
images of these pathology specimen grossing
procedures since 2010. The static images are integral
partsofoureducationaltoolsforpathologyresidents,
assistants, surgical pathology technicians, students
and, occasionally, our clinical colleagues for
presentation at rounds / multidisciplinary team
meetings as well as national and international
professionalmeetings.
WholeSlideImaging/VirtualMicroscopy
The development of whole slide imaging (WSI) has
made it possible to capture images of the entire
pathology slide. The creation of digital slides at high
resolution and multiple magnifications and focal
planes is intended to simulate light microscopy, also
referred to as virtual microscopy (VM). The robotic
microscopic scanner automatically scans glass slides
andemployssoftwaretocombineindividualscanned
fields into a composite digital image. (Pantanowitz
2012) The viewing software with userfriendly
interfaces makes it possible for the operator to
navigate to various regions of the virtual slide or
change magnifications. The WSI can be used for
primary pathological diagnosis, to capture static
images for reporting, archiving or computeraided
analysisandeducationalactivities.

Telepathology
Telepathology (TP) is the practice of pathology at a
distance using telecommunications technology to
facilitate the transfer of imagerich pathology data
between distant locations for the purposes of
diagnosis, education, and research. It is a singular
synchronous twoway communication between the
host and recipient. Telepathology, a name coined by
Dr. Ron Weinstein (Weinstein 1986), has also been
variously named: teleconsultation, telemicroscopy,
remoteroboticmicroscopy,teleconferencing,andweb
conferencing. Weinstein first reported TP and the
network of pathology diagnostic services on breast
tissues by remote workstationcontrolled light
microscopeattachedtoahighresolutionvideocamera
andatelecommunicationlinkage.(Weinstein1987)TP
with similar analog technologies has been used for
remote frozen section services in northern Norway
since1990.(Nordrum1995)Withtheadventofdigital
technologies, and the FDAapprovalfor use of digital
pathology for primary diagnosis, today, beyond the
use in surgical pathology, TP is also being employed

The traditional pathology glass slides for teaching

purposes are limited by the number of viewing
pathologistsorpathologistsintrainingtobesharedin
a multiheaded microscope, restricted access to the
traineesandlimitednumbersofslidestoberecutand
the stain quality deterioration over time. In contrast,
theWSIslidesaremoreinteractivethanstaticimages,
easier to share with multiple users anywhere and at

165

www.jitae.orgJournalofInformationTechnologyandApplicationinEducationVol.3Iss.4,December2014

employed using the Internet proper as a backbone.

However, WSI/VM telepathology is emerging as the
technologyofchoiceforTPeducation,despitesimilar
disadvantages as realtime TP. Several commercial
systemsarenow available at reasonable price.Recent
advances in storage technology allow for the large
digital files of WSI to be stored in local or cloud
servers, which storing and simultaneously retrieving
aremadepossible.

in telecytopathology, ultrastructural telepathology,

andtelehematology.(Pantanowitz2010)
TelepathologySystems
Thethreemajortelepathologysystemscurrentlyused
are static, realtime, and WSI/virtual microscopy. In
the static digital telepathology system, precaptured
still digital images are stored on a server. In an
example of TP session in Canada, on teleconference
time, the presenter (the pathology specialist) and
participating audience from across Canada logonto
the remote server, the userfriendly interface appears
andthestaticDPslidesaredownloadedautomatically,
andtheconferencebegins.Thedisadvantagesofstatic
TP are that the telepathologist presenter controls
everything including acquiring the images, while the
audiencearepassiveparticipants.Inteleconsultation,
theconsultantpathologisthasnoremotecontrolofthe
glass slide and has limited fields of view to examine.
However, static TP systems are welcome in the parts
of the world with limited resources, shortages of
trained personnel and lack of continuing education
programs.Itisconsideredtobeasimple,costeffective,
reliableandefficientmeanstoprovidediagnosticand
educational support to pathologists in the developing
world.(Sohani2012)

Social Media and Mobile Device Use

The advances in computing power and the
exponential growth of internet search for learning
resources have permitted the establishment of
powerful new webbased technologies and
technologiesforwebpublicationanddigitaleducation.
Digitalatlases,virtualslideteachingsetsandWSI/VM
havebeencreatedforelearninganddigitaleducation.
(Fung 2012, Nguyen 2014) An example of a robust
website
recommended
for
pathologists
is
PathologyOutlines.com which was created by wiki
technology.Awikiisdefinedasawebpageinwhich
thecontentscanbeeditedbyusersinrealtimeusinga
webbrowser. (Rasmussen 2013) Wiki software is of
particular interest to medical education because of its
emphasis on largescale collaborationand publication
of articles. (Park 2012) Skype is a popular and free
software application that allows personal computers
and mobile devices to be used for video
communication over the Internet. Videos can be
uploaded to YouTube, a popular video sharing
website, and downloaded for educational use. (Solez,
2011) Telepathology using smart phones and tablets
with Skype and MSN for live, synchronous online
communication are feasible for clinical and
educational uses. (Armfield 2012, Bellina 2009, Klock
2008) The use of an iPAD tablet or similar android
devicetodownloadDPslidesfromaWebserverforE
learning has been found to provide satisfactory
solutioninlowresourcecountries.(Fontelo2012)Ina
review of social media use in medical education,
(Cheston2013)theincorporationofsocialmediatools
promoted learner engagement, feedback and
collaborationandprofessionaldevelopment.Themost
commonly cited challenges were technical issues,
variable learner participation and privacy/security
concerns.

ThegeographyofCanadawithcitiesseparatedbyvast
distances suggests that telepathology may have a
particularly promising future in this country. The
University Health Network (UHN) is a multisite
academic institution in Toronto, comprising several
downtownhospitalsandremotehospitalsinNorthern
Ontario. WSI has been effectively utilized for
telepathologyinprimaryfrozensectiondiagnosisand
secondary/tertiary teleconsultation. (Evans 2009,
Pantanowitz 2011) In the Province of Quebec,
implementation of the Eastern Quebec telepathology
projectprovidesuniformfrozensectiondiagnosisand
teleconsultation services across a huge geographic
region comprising 21 sites. (Tetu 2012) Realtime and
WSI/virtual microscopy in TP systems offer higher
diagnostic accuracy and faster turnaround time and
are most suitable for clinical applications. The
disadvantages of realtime robotic TP system include
the need for high bandwidth, highly experienced
personnel;thatequipmentisstillexpensiveandslow,
both host and recipient require integrated software
and video conferencing equipments. (Pantanowitz
2010) The imagerich sessions perform best on local
area networks, and performance may suffer and data
security is also one of the challenges if these are

166

Challenges of Digital Pathology Education

Digital pathology is a rapid evolving niche in the
world of pathology. In a recent Scientific American

JournalofInformationTechnologyandApplicationinEducationVol.3Iss.4,December2014www.jitae.org

reviewofDP,(May2010)theeditorshavepointedout
that a remake of pathology is overdue; that emerging
techniques allow computerized images to be
manipulated,andthatdigitalpathologywillallowfor
moreprecisediagnoses.Lately,however,theadoption
ofdigitalpathologyhasbeenslowerthantheadoption
of digital images in radiology, although both
disciplines require imaging modality to collect
primarydata.Thisisrelatedtothefactthatradiology
images are primarily acquired as digital data and
differentpicturearchivingsystems.(Pantanowitz2011)
In a recent survey of pathology residents and staff in
Canada, the results showed that telepathology was
used in less than half of the institutions, mainly for
teaching, followed by operating room consultations.
Majority of the pathologists and residents use digital
imagesintheirpracticeandbelievethereisaneedfor
TPintheirpractice.(Bellis2013)

review of the evidence base. J Telemed Telecare. 2012;

18(3):1257.
Bellina L, and Missoni E. Mobile cellphones (Mphones) in
telemicroscopy: Increasing connectivity of isolated
laboratories.DiagnPathol2009;4:19.
BellisM,MetiasS,NauglerC,PollettA,JothyS,YousefGM.
Digital pathology: Attitudes and practices in the
Canadian pathology community. J Pathol Inform. 2013
Mar14;4:3.
ChesterCC,FlickingerTE,ChisolmMS.Socialmediausein
medical education: a systemic review. Acad Med
2013;88(6):893901.
DeeFR,andMeyerholzDK.Teachingmedicalpathologyin
thetwentyfirstcentury:Virtualmicroscopyapplications.
JVetMedEduc2007;34(4):4316.
Evans AJ, Chetty R, Clarke BA, Croul S, Ghazarian DM,

ThelimitationsinimplementationofDPineducation
include: 1. Infrastructure and resources supports. The
costofacquisitionandmaintenanceofDPequipments,
networking equipment and personnel expenses are
very high. 2. Integration into existing laboratory
information system (LIS) or Provincial Health
Network(PHN)portalssuchastheNetcareinAlberta
rather than a standalone DP education system may
attract investments from government or the private
sector. 3. Acceptance of digital pathology images in
the diagnosis, with FDA or Canadian authority
approval.4.Engagementofallpathologistsinpractice
orintraining.

KiehlTR,PerezOrdonezB,IlaalaganS,AsaSL.Primary
frozen section diagnosis by robotic microscopy and
virtual slide telepathology: The University Health
NetworkExperience.HumPathol2009;40(8):107081.
Fontelo P, Faustorilla J, Gavino A, Marcelo A. Digital
pathology implementation challenges in lowresource
countries.AnalCellPathol(Amst)2013;35(1):3136.
FosterK.Medicaleducationinthedigitalage:Digitalwhole
slideimagingasanelearningtool.JPatholInform2010
Aug10;1,pii:14.
Fung KM, Hassell LA, Talbert ML, Wiechmann AF, Chaser

Conclusions

BE, Ramev J. Whole slide images and digital media in

pathologyeducation,testingandpractice:theOklahoma

In conclusion, the rapid advancement of information

technology and emerging techniques has allowed the
gradual acceptance of digital pathology and
telepathology. The use of DP and TP in clinical
services is well recognized in multisite medical
centres as well as in geographically diverse health
sites. Their uses in education are somewhat limited,
due to limited funding of infrastructures and
technologiesandlimitedbandwidthfortransmission.

experience.AnalCellPathol(Amst)2012;35(1):3740.
Khalbuss WE,Pantanowitz L, Parwani AV.Digital imaging
incytopathology.PathologResInt2011:2011:264683.
Klock C, and Gomes Rde P. Web conferencing systems:
Skype and MSN in telepathology. Diagn Pathol
2008;3:S13.
May,Mike.Abetterlensondisease.SciAm2010;10:747.
Monaco SE, Kant P, Carter G, Trucco G, KanbourShakir A,

REFERENCES

Elishaev E. A Virtual Slide Box using whole slide

imaging for reproductive pathology education for

AminM,SharmaG,ParwaniAV,AndersonR,KolowitzBJ,

medicalstudents.ModPathol2011;24:132A.

Piccoli A, Shrestha RB, Lauro GR, Pantanowitz L.

Nordrum I, and Eide TJ. Remote frozen section service in

Integration of digital gross pathology images for

Norway.ArchAnatCytolPathol1995;43(4):2536.

enterprisewideaccess.JPatholInform2012Mar16;3:10.

NguyenK.http://pathology.ubc.ca/educationresource/dhplc

Armfield NR, Gray LC, Smith AC. Clinical use of Skype: a

167

www.jitae.orgJournalofInformationTechnologyandApplicationinEducationVol.3Iss.4,December2014

/dhplcbooks/cytologyseriesbydrnguyen/.

implementing

Pantanowitz L. Digital images and the future of digital

patientoriented

telepathology

network; the Eastern Quebec telepathology project

pathology.JPatholInform2010Aug10;1.pii:15.

experience.AnalCellPathol(Amst)2012;35(1):1118.

PantanowitzL,ValensteinPN,EvansAJ,KaplanKJ,Pfeifer

WeakerFJ,andHerbertDC.Transitionofadentalhistology

JD, Wilbur DC, Collins LC, Colgan TJ. Review of the

course from light to virtual microscopy. J Dent Educ

current state of whole slide imaging in pathology. J

2009;73:121321.

PatholInform2011;2:36.

Weinstein, RS. Prospects for telepatholgy (Editorial),Hum

Pantanowitz L, Szymas J, Yagi Y, Wilbur D. Whole slide

Pathol1986;17:443434.

imaging for educational purposes. J Pathol Inform 2012;

Weinstein RS, Bloom KJ, Rozek LS. Telepathology and the

3:46.

networkingofpathologydiagnosticservices.ArchPathol

Park S, Parwani A, Macpherson T, Pantanowitz L. Use of a

LabMed1987;111(7):64652.

wiki as an interactive teaching tool in pathology

Brian K. Chiu is Associate Professor of Pathology, at the

University of Albert, Edmonton, Alberta, Canada. Dr. Chiu
graduated as Doctor of Medicine and obtained specialty
certification in Anatomical Pathology, FRCP(C) Canada.He
is now a Senior Anatomical Pathologist, with specialty
interests in Cardiovascular, Pulmonary, Transplant
PathologyandDigitalPathologyinEducation.

residency education: Experience with a genomics,

research, and informatics in pathology course. J Pathol
Inform2012;3:32.
PathologyOutlines.http://pathologyoutlines.com/.
Rasmussen A, Lewis M, White J. The application of wiki
technology in medical education. Med Teacher 2013;

Kim Solez is Professor of Pathology at the University of

Alberta, Edmonton, Canada. Dr. Solez created the Banff
Classification, the worldwide standard for interpretation of
solid organ transplant biopsies and directs the biannual
meetingsthatupdateandrefinethatclassification.Forover
22 years he has been using new technologies to create
consensus in medicine, and since 2011 has been teaching a
unique multidisciplinary course on Technology and the
Future of Medicine. Dr. Solez also directsthe Faculty of
Medicine and Dentistrys global health program in Nepal
thatnowinvolvesovertwentyfacultymembers.

35(2):109114.
Sergi C, and Mikuz G. External quality assurance as a
revalidation method for pathologists in pediatric
histopathology: Comparison of four international
programs.BMCClinPathol.2008;8:11.
SharmaG,KellySM,WiehagenLT,PalekarA,Pantanowitz
L, Parwani AV. Implementation of whole slide imaging
for multisite review of performance improvement
program(PIP)slides.ArchPathLabMed2011;135:12278.

Consolato M. Sergi is Professor of Pathology and Adjunct

Professor, Department of Pediatrics, University of Alberta,
Edmonton,Canada.Dr.SergiobtainedhisMDdegreeatthe
University of Genoa, Italy, PhD at the University of
Innsbruck, Austria, and his FRCPC (Canada) in 2013. Dr.
Sergis specialty areas of interest arePediatric and Adult
Liver Disease, Congenital Heart Disease and Metabolic
Diseases, andResearch topics include:Pathology and
GeneticsofHepatoRenalFibrocysticDiseases,Pathogenesis
of Hepatocellular and Cholangiocellular Carcinoma and
MitochondrialDNArelatedCardiomyopathies.

Sohani AR, and Sohani MA. Static digital telepathology: A

model for diagnostic and educational support to
pathologists in the developing world. Anal Cell Pathol
(Amst)2012;35(1):2530.
SolezKandOlsonNL,TheAIPhysician:EducationalVideo
for the Lifeboat Foundation, 2011 https://www.
youtube.com/watch?v=kzo3vUxUkzY.
TetuB,FortinJP,GagnonMP,LouahliaS.Thechallengesof

168